Closing the gap between research and practice: an overview ...

1 Home > Volume 317, Number 7156 > BMJ 317 : 465 (Published 15 August 1998) BMJ BMJ 317 : 465 (Published 15 August 1998) Education and debate Getting research findings into practice Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings Lisa A Bero, associate professora, Roberto Grilli, headb, Jeremy M Grimshaw, programme director Emma Harvey, research fellowd, Andrew D Oxman, directore, Mary Ann Thomson, senior research fellowc Author Affiliations c Correspondence to: Dr Grimshaw This is the seventh in a series of eight articles analysing the gap between research and practice Series editors: Andrew Haines and Anna Donald Despite the considerable amount of money spent on clinical research relatively little attention has been paid to ensuring that the findings of research are implemented in routine clinical practice.

2 There are many different types of intervention that can be used to promote behavioural change among healthcare professionals and the implementation of research findings. Disentangling the effects of intervention from the influence of contextual factors is difficult when interpreting the results of individual trials of behavioural change. Nevertheless, systematic reviews of rigorous studies provide the best evidence of the effectiveness of different strategies for promoting behavioural change. In this paper we examine systematic reviews of different strategies for the dissemination and implementation of research findings to identify evidence of the effectiveness of different strategies and to assess the quality of the systematic reviews.

3 Summary points Systematic reviews of rigorous studies provide the best evidence on the effectiveness of different strategies to promote the implementation of research findings Passive dissemination of information is generally ineffective It seems necessary to use specific strategies to encourage implementation of research based recommendations and to ensure changes in practice Further research on the relative effectiveness and efficiency of different strategies is required Identification and inclusion of systematicreviews We searched Medline records dating from 1966 to June 1995 using a strategy developed in collaboration with the NHS Centre for Reviews and Dissemination.

4 The search identified 1139 references. No reviews from the Cochrane Effective Practice and Organisation of Care Review Group had been published during this time. In addition, we searched the Database of Abstracts of research Effectiveness (DARE) ( ) but did not identify any other review meeting the inclusion criteria. We searched for any review of interventions to improve professional performance that reported explicit selection criteria and in which the main outcomes considered were changes in performance or outcome. Reviews that did not report explicit selection criteria, systematic reviews focusing on the methodological quality of published studies, published bibliographies, bibliographic databases, and registers of projects on dissemination activities were excluded from our review.

5 If systematic reviews had been updated we considered only the most recently published review. For example, the Effective Health Care bulletin on implementing clinical guidelines superseded the earlier review by Grimshaw and Russell. +1234456 Page 1 of 12 Closing the gap between research and practice: an overview of systematic reviews of Two reviewers independently assessed the quality of the reviews and extracted data on the focus, inclusion criteria, main results, and conclusions of each review. A previously validated checklist (including nine criteria scored as done, partially done, or not done) was used to assess quality. Reviews also gave a summary score (out of seven) based on the scientific quality of the review.

6 Major disagreements between reviewers were resolved by discussion and consensus. Resultsand assessment of systematic reviews We identified 18 reviews that met the inclusion criteria. They were categorised as focusing on broad strategies (such as the dissemination and implementation of guidelines 9 ), continuing medical education, particular strategies (such as audit and feedback, computerised decision support systems, or multifaceted interventions), particular target groups (for example, nurses or primary healthcare professionals), and particular problem areas or types of behaviour (for example, diagnostic testing, prescribing, or aspects of preventive care ).

7 Most primary studies were included in more than one review, and some reviewers published more than one review. No systematic reviews published before 1988 were identified. None of the reviews explicitly addressed the cost effectiveness of different strategies for effecting changes in behaviour. There was a lack of a common approach adopted between the reviews in how interventions and potentially confounding factors were categorised. The inclusion criteria and methods used in these reviews varied considerably. Interventions were frequently classed differently in the different systematic reviews. Common methodological problems included the failure to adequately report criteria for selecting studies included in the review, the failure to avoid bias in the selection of studies, the failure to adequately report criteria used to assess validity, and the failure to apply criteria to assess the validity of the selected studies.

8 Overall, 42% (68/162) of criteria were reported as having been done, 49% (80/162) as having been partially done, and 9% (14/162) as not having been done. The mean summary score was (range 2 to 6, median , mode 3). Encouragingly, reviews published more recently seemed to be of better quality. For studies published between 1988 and 1991 (n=6) only 20% (11/54) of criteria were scored as having been done (mean summary score ); for reviews published after 1991 (n=12) 52% (56/108) of criteria were scored as having been done (mean summary score ). Five reviews attempted formal meta-analyses of the results of the studies identified.

9 The appropriateness of meta-analysis in three of these reviews is uncertain, and the reviews should be considered exploratory at best, given the broad focus and heterogeneity of the studies included in the reviews with respect to the types of interventions, targeted behaviours, contextual factors, and other research number of consistent themes were identified by the systematic reviews (box). (Further details about the systematic reviews are available on the BMJ's website.) Most of the reviews identified modest improvements in performance after interventions. However, the passive dissemination of information was generally ineffective in altering practices no matter how important the issue or how valid the assessment methods.

10 The use of computerised decision support systems has led to improvements in the performance of doctors in terms of decisions on drug dosage, the provision of preventive care, and the general clinical management of patients, but not in diagnosis. Educational outreach visits have resulted in improvements in prescribing decisions in North America. Patient mediated interventions also seem to improve the provision of preventive care in North America (where baseline performance is often very low). Multifaceted interventions (that is, a combination of methods that includes two or more interventions such as participation in audit and a local consensus process) seem to be more effective than single interventions.